CHECKLIST: Review of Systems ---------------------------------------------------------------------------------

Checklist: ------------------------------------
General- Breasts-
□ Weight loss or gain □ Lumps
□ Fatigue □ Pain
□ Fever or chills □ Discharge
□ Weakness □ Self-exams
□ Trouble sleeping □ Breast-feeding
--------------------------------------------------------------------------------- ---------------------------------------------------------------------------------
------------------------------------ ------------------------------------
Skin- Respiratory-
□ Rashes □ Cough (dry or wet,
□ Lumps productive)
□ Itching □ Sputum (color and
□ Dryness amount)
□ Color changes □ Coughing up blood
□ Hair and nail changes (hemoptysis)
--------------------------------------------------------------------------------- □ Shortness of breath
------------------------------------ (dyspnea)
Head- □ Wheezing
□ Headache □ Head injury □ Painful breathing
--------------------------------------------------------------------------------- Cardiovascular-
------------------------------------ □ Chest pain or discomfort
Ears- □ Tightness
□ Decreased hearing □ Palpitations
□ Ringing in ears (tinnitus) □ Shortness of breath with
□ Earache activity (dyspnea)
□ Drainage □ Difficulty breathing
--------------------------------------------------------------------------------- lying down (orthopnea)
------------------------------------ □ Swelling (edema)
Eyes- □ Sudden awakening from
□ Vision sleep with shortness of
□ Glasses or contacts breath (Paroxysmal
□ Pain Nocturnal Dyspnea)
□ Redness ---------------------------------------------------------------------------------
□ Blurry or double vision ------------------------------------
□ Flashing lights Gastrointestinal-
□ Specks □ Swallowing difficulties
□ Glaucoma □ Heartburn
□ Cataracts □ Change in appetite
□ Last eye exam □ Nausea
--------------------------------------------------------------------------------- □ Change in bowel habits
------------------------------------ □ Rectal bleeding
Nose- □ Constipation
□ Stuffiness □ Diarrhea
□ Discharge □Yellow eyes or skin
□ Itching (jaundice)
□ Hay fever ---------------------------------------------------------------------------------
□ Nosebleeds ------------------------------------
□ Sinus pain Urinary-
--------------------------------------------------------------------------------- □ Frequency
------------------------------------ □ Urgency
Throat- □ Burning or pain
□ Teeth □ Blood in urine
□ Gums (hematuria)
□ Bleeding □ Incontinence
□ Dentures □ Change in urinary
□ Sore tongue strength
□ Dry mouth ---------------------------------------------------------------------------------
□ Sore throat ------------------------------------
□ Hoarseness Genital-
□ Thrush Male-
□ Non-healing sores □ Pain with sex
□ Last dental exam □ Hernia
--------------------------------------------------------------------------------- □ Penile discharge
------------------------------------ □ Sores
Neck- □ Masses or pain
□ Lumps □ Erectile dysfunction
□ Swollen glands □ STD’s
□ Pain Female-
□ Stiffness □ Pain with sex
□ Vaginal dryness Vision
□ Hot flashes
□ Vaginal discharge
□ Itching or rash Chronic or past eye disorders?
□ STD’s
--------------------------------------------------------------------------------- Decrease/change in vision or blurriness? With or without pain?
------------------------------------
Vascular- Double vision?
□ Calf pain with walking
(Claudication) Eye discharge (D/C)?
□ Leg cramping
--------------------------------------------------------------------------------- Change in color of structures?
------------------------------------
Musculoskeletal- Head and Neck (H&N)
□ Muscle or joint pain
□ Stiffness
□ Back pain Chronic or past head and neck disorders?
□ Redness of joints
□ Swelling of joints Pain?
□ Trauma
--------------------------------------------------------------------------------- Sores or non-healing ulcers in/around mouth?
------------------------------------
Neurologic- Masses or growths?
□ Dizziness
□ Fainting Change in hearing acuity?
□ Seizures
□ Weakness Ear pain or discharge?
□ Numbness
□ Tingling Nasal discharge, post nasal drip?
□ Tremor
--------------------------------------------------------------------------------- Change in voice/hoarseness?
------------------------------------
Hematologic- Tooth pain or problems?
□ Ease of bruising □ Ease of bleeding
---------------------------------------------------------------------------------
------------------------------------ Pulmonary
Endocrine-
□ Head or cold intolerance Chronic or past pulmonary disorders?
□ Sweating
□ Frequent urination Shortness of breath - @ rest or w/exertion?
(polyuria)
□ Thirst (polydypsia) Chest pain?
□ Change in appetite
(polyphagia) Cough?
---------------------------------------------------------------------------------
------------------------------------ Hemoptysis (coughing up blood)?
Psychiatric-
□ Nervousness Wheezing?
□ Depression
□ Memory loss Snoring or stop breathing?
□ Stress

Cardiovascular (C/V)
General

Chronic cardiovascular disorders?

Weight loss?
Chest pain (CP) or pressure?
Weight gain?
Shortness of breath - @ rest or w/exertion?
Fatigue?
Orthopnea (short of breath lying down)?
Difficulty sleeping?
Paroxysmal Nocturnal Dyspnea (PND)? - sudden shortness of
Feeling well (or poorly) in general? breath that awakens pt from sleep
Recent medical evaluations or treatments? Lower extremity edema?
Chronic pain? Sudden loss of consciousness (syncope)?
Fevers, chills, sweats, weight loss? Sense of rapid or irregular heart beat, palpatations?
 Ob/Gyn/Breast
Calf/leg pain/cramps w/ambulation?
Chronic or past disease?
Wounds/ulcers in feet? Difficult/slow to heal?
Menstrual Hx?
Gastrointestinal
Sweats?
Chronic or past GI disorders?
Past pregnancies?
Heart burn/sub-sternal burning?
Vaginal Discharge?
Abdominal pain?
# Sexual partners & type of sexual activity?
Difficulty swallowing?
Breast mass, pain or discharge?
Pain upon swallowing?
Therapeutic or spontaneous abortions?
Nausea or Vomiting?
Hx STIs?
Abdominal swelling or distention?
Neurological
Jaundice (yellowish coloration of skin)?
Known disease?
Vomiting blood (hematemasis)?
Sudden loss of neurological function?
Black/tarry stools?
Abrupt loss/change in level of consciousness?
Bloody stools?
Witnessed seizure activity?
Constipation?
Numbness?
Diarrhea or other change in bowel habits?
Weakness?
Genito-Urinary
Dizziness?
Chronic or past GU disorders?
Balance problems?
Blood in urine?
Headache?
Burning with urination?
Tremor?
Urination at night?
Endocrine
Incontinence (unintentional loss of urine)?
Known Endocrine disorder?
Urgency?
Polyuria, polydypsia, polyphagia?
Frequency?
Fatigue?
Incomplete emptying? Hesitancy? Decreased force of stream?
Need to void soon after urinating?
Weight loss?
For Men:
Weight gain?

Hematology/Oncology
Infectious Diseases

Chronic or past Heme/Onc disease?

Known disease?
Fevers, chills, sweats, weight loss?
Fevers, Chills, Sweats?
Abnormal bleeding/brusing?
Musculoskeletal
New/growing lumps or bumps?
Known disease?
Hypercoaguability?
Joint pain?
Muscle ache?

Joint swelling?

Joint redness?

Low back pain?

Mental Health

Known mental health disorder?

Do you feel sad or depressed much of the time?

Alcohol, other substance abuse?

Anxious much of the time?

Memory problems?

Confusion?

Skin and Hair

Hair Loss

Known disease?

Skin eruptions/rashes?

Growths?

Sores that grow and/or don't heal?

Lesions changing in size, shape, or color?

Itching?